MEDICAL EXAMINATION
FOR APPLICANTS FOR A HACKNEY
CARRIAGE OR PRIVATE HIRE VEHICLE
DRIVER’S LICENCE
Notes for the applicant
THIS MEDICAL MUST BE COMPLETED BY A DOCTOR IN YOUR REGISTERED GROUP PRACTICE.
If you knowingly give false information in this examination you are liable to prosecution.
Before you can be issued with a licence to drive a hackney carriage or private hire vehicle the Council
must be satisfied that you are fit for this type of driving. For this reason, your registered Doctor must fill
in Part B of this Medical Report.
You should then send it with your application to:
Weymouth and Portland Applications:
Licensing Department
Weymouth & Portland Borough Council
Council Offices
North Quay
Weymouth
Dorset
DT4 8TA
West Dorset Applications:
Licensing Department
c/o Weymouth & Portland Borough Council
Council Offices
North Quay
Weymouth
Dorset
DT4 8TA
Failure to do so will delay the processing of your application.
Your Doctor will not be able to give you this report free under the National Health - you may have to pay a
fee. If you have any doubts about your fitness, consult your Doctor before you take this form to him for
an examination.
Please fill in Part A of this form, make sure that you answer all the questions. Please write in CAPITALS.
Do not sign the authorisation at 9 until you are with the Doctor who is going to fill in Part B of the
report.
Part A
To be filled in by the applicant
Please answer all the questions and write in CAPITALS
If you have held a hackney carriage/private hire vehicle
drivers licence before, when was your first licence issued
and which authority issued it
Date of first licence
If you have held a PCV/LGV drivers licence issued by the
DVLA, when did you last pass the medical required for that
licence
Date of DVLA
Medical (if appropriate)
Issuing authority
Date of Birth
1. Full name
2. Address
Home telephone number
Work telephone number
Postcode
3. Give the name and address of the doctor (or group practice) that you have been registered with for
the last 12 months
Name(s)
Address
Postcode
Notes for the Doctor
Please read these notes before undertaking the examination.
Please complete Part B of this report, having regard to the 'Notes for Guidance' (1991 edition) published by
the British Medical Association for Doctors conducting these examinations and where necessary, to the
booklet 'Medical Aspects of Fitness to Drive' (1985 edition) published by the Medical Commission for
Accident Prevention, and the DVLA's 'At a Glance Guide'.
If you have any doubt about the applicant's fitness for this type of driving, please contact
Licensing on 01305 838026.
Please tick the answer that applies and complete all answers.
The purpose of the report is to determine the applicant's fitness to drive hackney carriages/private
hire vehicles.
The council may need to make further enquiries if there is any doubt as to the applicant's fitness.
The medical standards for hackney carriage/private hire vehicle driver licences are higher than they are for
ordinary driving entitlement. These standards are briefly explained below.
By Law a licence may not be issued if the applicant:



has had an epileptic fit attack during the last 10 year period and/or has taken anti-epileptic medication
during that same period; or
has visual acuity worse than 6/7.5 in the better eye or worse than 6/12 in the other eye or if corrective
lenses are worn, has an uncorrected acuity in either eye of less than 3/60 unless he/she held a valid
licence on 1.1.83 and still held such a licence on 1.4.91 when a lower standard will apply; or
is a new monocular driver unless he/she held a valid licence on 1.4.91 and the Traffic Commissioner
who issued the licence had knowledge of the condition before 1.1.91 and he/she has a visual acuity of
not less than 6/7.5 in the remaining eye (or 6/12 if he/she was issued with a licence before 1.1.83); or
is an insulin dependent diabetic, unless he/she held a valid licence on 1.4.91 and the Traffic
Commissioner who issued that licence had knowledge of the condition before 1.1.91 or the C1/C1E
exemption criteria are met.
In addition the licence may be refused if the applicant:










has had a myocardial infarction, CABG or coronary angioplasty
suffers persistent arrhythmia
has uncontrolled established hypertension
has had a stroke, TIA, or unexplained loss of consciousness
has had severe head injury with continuing after-effects, or major brain surgery
has Parkinson's disease, multiple sclerosis or Meniere's disease
is being treated for or has suffered a psychotic illness in the past 5 years
has had alcohol or drug addiction problems in the past 5 years
has serious difficulty communicating by telephone
has diplopia or visual field defect
has any other condition which would cause problems for hackney carriage/private hire vehicle driving
unless the applicant can prove that he/she is otherwise medically fit to obtain a licence.
Important -Any essential, additional information should be given in a separate letter and
attached.
Part B
Medical Examination - to be completed by a Doctor in the Group
Practice with whom the applicant is registered
Please give patient's weight
Give details of smoking habits, if any
What is his/her alcohol consumption?
(kg/st) and height
(cms/ft)
PLEASE ANSWER ALL QUESTIONS
Section 1 Vision
Note:
Visual acuities must be measured by Snellen chart (using spectacles or contact lenses if required).
If in doubt, please refer to local optician for assessment.
The applicant must meet 6/7.5 or better in one eye and 6/12 or better in the other (See NOTES p2) .
Yes
a
No
Does he/she fail to meet this standard?
If 'Yes', please state: i. the acuities without lenses: ii. Acuities corrected by lenses:
Left:
Right:
Left:
Right:
b
Where glasses are worn, are their corrective power ≥+ 8 droptres
c
Is the uncorrected visual acuity in either eye worse than 3/60 (equivalent to
reading 6/60 line at 3 metres) without the use of spectacles or contact lenses?
d
Is the applicant without sight in one eye?
Please give date when he/she became monocular
e
Is there diplopia or evidence of a pathological field defect - eg hemianopia
or quadrantanopia?
If Section 1 completed by Optician:-
Optician’s Address: ………………………………………………..……………..
Optician’s Name: …………………………… Signature: ……………………..…….. Dated: ………………………….
Section 2 Nervous System
Yes
a
Has there been an epileptic attack during the last 10 years?
b
Has the applicant received anti-epileptic medication during the last 10 years?
c
Is there a history of an episode or episodes of unexplained altered consciousness?
d
Is there a history of stroke, TIA, or vertebrobasilar insufficiency?
e
Is there a history of recurring Meniere's disease?
f
Is there evidence of multiple sclerosis?
g
Is there evidence of Parkinson's disease?
h
Is there a history of major brain surgery?
i
Is there a history of serious head injury with evidence of an intra-cerebral
haematoma or compound depressed skull fructure?
j
Is there serious difficulty preventing adequate communication by telephone?
k
Is there a history of unexplained syncope or disabling vertigo?
No
Section 3 Diabetes Mellitus
a
Does the applicant have diabetes mellitus? If 'Yes', please answer the following
questions. If 'No' proceed to Section 4.
b
Is the diabetes managed by:i.
insulin?
ii.
oral hypoglycaernic agents and diet?
iii.
diet only?
c
Is the control of the diabetes satisfactory?
d
Is there evidence of :i.
loss of peripheral visual field?
ii.
severe peripheral neuropathy?
iii.
significant impairment of limb function or joint position sense?
iv.
episodes of hypoglycaemia?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Section 4 Psychiatric Illness
a
Has the applicant suffered or required treatment for a psychotic illness in the past
five years?
b
Has the applicant required treatment for a mental disorder with psychotropic
medication within the past 6 months?
c
Is there confirmed evidence of dementia?
d
Is there a history of alcohol misuse in the last 5 years?
e
Is there a history of drug or substance misuse in the last 5 years?
Section 5 Musculoskeletal System
a
Has the applicant a significant disability of the spine which is likely to interfere with
the efficient discharge of his/her duties as a vocational driver?
b
Has the applicant any deformity, loss of limbs or parts of limbs, or physical disability
(with special attention paid to the condition of the arms, legs, hands and joints) which
is likely to interfere with the efficient discharge of his/her duties as a vocational driver?
Section 6 Malignant Growths
a
Is there a history of malignant brain lesion, either primary or secondary?
b
Is there a history of bronchogenic carcinoma?
Section 7 Other Conditions
Does the applicant suffer from any significant medical disability not metioned above,
which is likely to interfere with the efficient discharge of his/her duties as a vocational driver?
If 'Yes', please include details in a separate letter and attach it to this form.
Section 8 Cardiac
Coronary artery disease
a
Is there a history of, or evidence of:
i.
Myocardial infarction?
(if 'Yes' please give date(s))
b
ii.
Coronary artery by-pass graft (CABG)?
(if 'Yes' please give date(s))
iii.
Coronary angioplasty?
(if 'Yes' please give date(s))
iv.
Confirmed angina, whether or not treated symptomatically?
Cardiac arrhythmia and heart block
i.
Is there a history of persisting cardiac arrhythmia?
ii.
Is there history of paroxysmal cardiac arrhythmia, in past six months?
iii.
Has an ECG been undertaken?
(if 'Yes', what abnormality has been shown?)
iv.
c
d
Has a pacemaker been inserted?
Peripheral arterial disease
i.
Is there a history of aortic aneurysm, thoracic or abdominal, whether or not it has
been repaired?
ii.
Is there or has there been symptomatic peripheral arterial disease, with or
without surgical intervention?
Blood pressure
i.
Is the established blood pressure (to the nearest 5mm Mercury) 200/110 or over?
ii.
Is medication required?
If 'Yes', does it cause giddiness, fainting, lack of alertness or fatigue?
e
f
Valvular heart disease
i.
Is there evidence of valvular heart disease, with or without heart valve
replacement?
ii.
Is the applicant taking anti-coagulents for the valvular heart condition?
Other cardiac conditions
i.
Is there a history of dilated cardiomegaly or hypertrophic cardiomyopathy?
ii.
Has an X-Ray been undertaken?
If Yes, does it show significant enlargement of the heart, CTR>.55?
iii.
Has heart, or heart/lung transplant, or cardiac surgery other than CABG or
aortic aneurysm repair been undertaken?
iv.
Is there a history of congenital heart condition, whether or not treated
surgically?
Yes
No
Section 9 For Medical Practitioner
Medical Practitioner Details
Doctor’s details
Name
Surgery Stamp
Address
E-mail address
I confirm that I am the applicants GP / GP at the same surgery and have this day duly examined
the applicant, who has signed this form in my presence and who in my opinion is
FIT to drive a vehicle to Group 2 Entitlement*, that is Hackney Carriage or Private Hire Vehicle
(also included in this group are HGV and PSV).
Date
Signature of Medical Practitioner
OR
UNFIT to drive a vehicle to Group 2 Entitlement*, that is Hackney Carriage or Private Hire
Vehicle (also included in this group are HGV and PSV).
Date
Signature of Medical Practitioner
* Issued by Drivers Medical Group, DVLA, Swansea, A Guide to the Current Medical Standards of Fitness to Drive.
https://www.gov.uk/government/publications/at-a-glance
Section 10
Access to Medical Records Act & Authority for the Release of Medical Information
To be completed by the applicant whilst in the presence of the Dr completing the medical – Please
use capital letters
Surname
Date of Birth
Forenames
Address
Telephone Number
APPLICATION FOR HACKNEY CARRIAGE/PRIVATE HIRE DRIVERS
Name of Medical Practitioner
Address
Telephone Number
I hereby consent to a medical report being supplied, in confidence, to the appointed Medical
Advisor.
I have read the summary of my rights overleaf and other relevant provisions under the Access to
Medical Reports Act 1988.
(*delete as appropriate) *I do / I do not wish to have access to the medical report before it is
supplied.
Signed……………………………………………………………………………………………………….
Date…………………………………………………………………………………………………………..
ACCESS TO MEDICAL REPORTS ACT 1988
This is a summary of your principal rights under the Act, which is concerned with reports
provided for employment or insurance purposes by a medical practitioner who is, or has
been responsible for your clinical care.
Option A
You may withhold your consent to an application for the report from a medical practitioner.
Option B
You may consent to the application, but indicate your wish to see the report before it is supplied. (You must
make the necessary arrangements with the medical practitioner to see the report; it will not be sent to you
automatically)
The medical practitioner will be informed that you wish to have access to the report and will allow 21 days
for you to see and approve it before it is supplied to the applicant. If the medical practitioner has not heard
from you in writing within 21 days of the application for the report being made he/she will assume that you
do not wish to see the report and that you consent to its being supplied.
When you see the report, if there is anything in it which you consider incorrect or misleading you can
request (but this request must be in writing) that the medical practitioner amend the report but he/she is not
obliged to do so. If the medical practitioner refuses to amend it you may
i)
ii)
iii)
withdraw consent for the report to be issued
ask the medical practitioner to attach to the report a statement setting out your own views
agree to the report being issued unchanged
Note: The medical practitioner is not obliged to show you any parts of the report which he/she believes
might cause serious harm to your physical or mental health or that of others, or which would reveal
information about a third party or the identity of a third party who has supplied the practitioner with
information about your health, unless the third party also consents. In those circumstances the medical
practitioner will so inform you and your access to the report will be appropriately limited.
OPTION C
You may consent to the application for the report but indicate that you do not wish to see the report before
it is supplied. Should you change your mind after the application is made and notify the medical practitioner
in writing he/she should allow 21 days to elapse after such notification so that you may arrange to have
access to the report (if the report has not already been supplied before you change your mind)
OPTION D
Whether or not you decide to seek access to the report before it is supplied, you have the right to seek
access to it from the medical practitioner at any time up to six months after it was supplied.
Please note that where a copy of the medical report is supplied to you the practitioner may
charge a reasonable fee to cover the cost of supplying it.